Accountable Care Organizations and the need to innovate

There is a lot of buzz over the creation of Accountable Care Organizations (ACOs) under the Patient Protection and Affordable Care Act (PPACA).

An ACO is a network of health care providers and hospitals that collaboratively manage patient care and prospective budgets. Perhaps the biggest draw of ACOs is the potential to create innovative ways to improve quality and decrease costs. To accomplish these goals, ACOs require the use of evidence-based medicine. Currently, supporters of ACOs have suggested financial incentives to encourage adoption of evidence-based best practices. Critics have derided the emphasis on best practices, calling it “cookbook” medicine because it hinders physician autonomy to make clinical decisions. As long as progress is being made, physicians can live with a decrease of autonomy. Just one small problem–financial incentives may impede medical progress by restricting innovation.

The vast majority of research has focused on financial incentives schemes (e.g., pay-for-performance (P4P) and evidence-based medicine) and its affect on cost, quality, and access of care. Unfortunately, no research has been conducted examining the affect of financial incentives on medical innovation. However, behavioral psychology and behavioral economics research can teach health care reformers a thing or two.In short, the behavioral sciences researchers have found that financial incentives (i.e., rewards and penalties) are not effective for completing complex task which require and critical thinking and creativity. Daniel Pink, author of the book Drive: The Surprising Truth About What Motivates Us, discussed the topic on NPR:

Human beings have a natural urge for autonomy. […] There’s an Australian software company called Atlassian, and they do something once a quarter where they say to their software developers: You can work on anything you want, any way you want, with whomever you want, you just have to show the results to the rest of the company at the end of 24 hours. They call these things ‘FedEx days,’ because you have to deliver something overnight. That one day of intense autonomy has produced a whole array of software fixes, a whole array of ideas for new products, a whole array of upgrades for existing products.

Since then other companies have followed suit: Yahoo! has “Hack Days” and Abode has “JDI days.” These trends have been found in numerous other fields from education to sports. But perhaps these findings are not surprising to parents who do not monetarily reward their children for good grades, or anyone who has come up with a brilliant idea in the shower–extrinsic rewards and pressure to perform well do not breed creativity.

Medicine, of course, requires a great deal of critical thinking. And so, physicians are not immune to these effects. Instead of external rewards, intrinsic desire must be the base of what makes us be better doctors. It must be the code and accountability that makes practicing medicine a profession. And professionalism itself in entrenched in the principles of autonomy and a greater sense of purpose. Indeed, research shows that having a purpose behind one’s work leads to increased job performance.

Of course, there are a number of reasons to support evidence-based practices. It can be a force of good to inspire adherence to professional norms. Perhaps the best example is the change of the practice of anesthesiology in the 1980s. At the time, there were an egregious number of preventable errors committed by anesthesiologists. Through promotion of optimal standards of care, the American Society of Anesthesiologists improved outcomes. But even good intentions can have unintended negative consequences.

My concern is that payment tied to evidence-based medicine will decrease the impetus to innovate. What good is a “cookbook” medicine if you can’t update the recipes? Digression from standards of care could mean a loss of money, so there is not much incentive to deter from the status quo. Most importantly, innovation in medicine has the potential to positively affect the main measures of good health care: cost, quality, and access. And thus, measures to encourage and maintain innovation must be considered with the implementation of ACOs.

Kunmi Sobowale is a medical student.

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